In advance of the Centers for Medicare & Medicaid Services’ (CMS) public release of physician Medicare data—which could happen as soon as Wednesday—the AMA is working to prevent misinterpretation of what could be confusing billing and payment information for reporters and patients. The key take-away for the media: Verify the data before you publish.
CMS last week announced that it will make data about Medicare payments made to physicians in 2012 available to the public. According to CMS, the objective of the data release is to make the “health care system more transparent and accountable” so that patients can “make more informed choices about the care they receive.”
Patients, reporters, insurers and others will be able to view Medicare Part B claims data for individual physicians, including the number and type of health care services provided, the number of unique Medicare patients treated, the average charges submitted and the average amount Medicare paid for those services.
“Medicare claims data is complex and can be confusing,” the AMA said in a statement to reporters. “The manner in which CMS is broadly releasing physician claims data, without context, can lead to inaccuracies, misinterpretations and false conclusions.”
The AMA this week released guidance outlining the data set’s nine primary limitations that people need to consider when evaluating physicians’ information.
- The data could contain errors. Physicians don’t have a way to review or correct the information reported.
- Care quality can’t be assessed from the information reported. The data focuses solely on payment and utilization of services and doesn’t include explicit information about the quality of care provided.
- The reported number of services could be misleading. For instance, residents and other health care professionals under a physician’s supervision can file claims under his or her National Provider Identifier, and the data may not properly detail who performed the services.
- Billed charges and payments aren’t the same. CMS will report both the physician’s billed charge and the actual amount paid, which is set by the Medicare Physician Fee Schedule. Payments generally are much less than the billed amount.
- The data doesn’t represent the physician’s patient population. The data won’t include services related to non-Medicare patients or account for the complexities of the physician’s patient population; it is not risk-adjusted.
- Payment amounts vary based on where the service was provided. Medicare pays physicians less for services provided in a hospital outpatient department than for services provided in the physician’s office to reflect a difference in the practice costs. But Medicare makes another payment to the facility to cover its practice costs when services are provided in the outpatient department. That means that in reality, the total costs to Medicare and the patient may be higher when a service is provided in a facility setting.
- The data doesn’t enable clear comparisons of physicians. Specialty descriptions and practice types aren’t very specific, so physicians who appear to have the same specialty could serve very different types of patients and provide a dissimilar mix of services, making some subspecialists appear to be “outliers.”
- Important information is missing. The data does not account for patient mix or demographics. It also does not point out that a significant share of Medicare payments is used to cover such costs as office overhead, employee salaries, supplies and equipment. To make matters worse, the data includes reimbursements for physician-administered drugs but fails to explain that these payments are compensation for the price of the drugs themselves, many of which are very expensive and are required to treat such serious conditions as cancer and macular degeneration.
- Coding and billing rules differ over time and across regions. Changes to Medicare’s coding and billing rules need to be taken into account in any analysis because these rules frequently change over time and across different parts of the country.
